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Inhaled NITRIC OXIDE. i NO.

Nitric Oxide:. Nitric Oxide (NO) is a colorless, odorless gas that is only slightly soluble in water. NO has been detected in exhaled human breath. The majority of exhaled NO in normal humans appears to be derived from nasal bacterial flora (25 to 64 ppb), with lower concentrations measured in the mouth, trachea, and distal airway (1 to 6 ppb)..

Nitric Oxide:. Formula : NO IUPAC ID : Nitric oxide Molar mass : 30.01 g/mol Melting point : -164 °C.

Nitric Oxide - Mechanism of action. After inhalation, NO diffuses rapidly across the alveolar-capillary membrane into the subjacent smooth muscle of pulmonary vessels to activate soluble guanylate cyclase.

Nitric Oxide - Mechanism of action. Increased intracellular concentrations of cGMP relax smooth muscle via several mechanisms..

Nitric Oxide - Mechanism of action. cGMP-Kinase K+-channel activation Ca+-channel inhibition Intracellular Ca++ Vasodilatation.

iNO - Pharmacodynamics / Pharmacokinetics. Route of Administration: Inhalation The onset of Action: Rapid, dose-dependent onset within minutes. Absorption: Nitric oxide is absorbed systemically after inhalation. Nitric oxide crosses the pulmonary capillary bed, where it combines with oxyhemoglobin..

iNO - Pharmacodynamics / Pharmacokinetics. Metabolism: Nitric oxide combines oxygen and water, produces nitrogen dioxide and nitrite, and interacts with oxyhemoglobin to produce methemoglobin and nitrate. Consequently, the end products of nitric oxide metabolism are mainly methemoglobin and nitrate. Half-Life: 2 to 6 seconds.

iNO - Pharmacodynamics / Pharmacokinetics. Route of Elimination: 70% of inhaled NO metabolites undergo renal elimination. The kidney clears nitrate from the plasma at rates corresponding to the glomerular filtration rate..

Inhaled Nitric Oxide - Indications. Persistent pulmonary Hypertension in newborn Primary pulmonary hypertension Pulmonary hypertension after cardiac surgery Cardiac transplantation (Myocardial ischemia / Reperfusion injury) Acute pulmonary embolism Hypoxemic respiratory failure.

Inhaled Nitric Oxide - Contra Indications. Severe left ventricular dysfunction and Congenital heart disease involving right to left shunt ECHO should rule out Congenital Cyanotic heart disease before initiating iNO Abrupt discontinuation of iNO can worsen oxygenation and increase pulmonary artery pressure in rebound pulmonary hypertension syndrome..

Inhaled Nitric Oxide - Advantages. Odorless and colorless Rapid-acting, full response usually within minutes Rapid offset, very safe Short exposure time suitable for busy catheterization lab settings No systemic adverse effects due to immediate inactivation by combining with Hb to form methemoglobin..

Inhaled Nitric Oxide - Disadvantages. Administration technology very expensive at present Short duration of effect necessitates continuous administration if used long-term Requires cumbersome portable tanks for out-patient use at present Withdrawal syndrome consisting of deterioration of hemodynamics & gas exchange poses a potential impediment to long-term use..

Inhaled Nitric Oxide devices. Noxivent® | Linde. Life Support - SLE.

How to connect and monitor iNO. Connect the nitric oxide circuit with the machine Place the sample line in the proximal end of the inspiratory limb Place the nitric oxide line before the humidifier ABG to follow before starting iNO to check the baseline of values of Po2, Pco2 and MetHb iNO should be started at 20PPM.

How to connect and monitor iNO. ABG should check after one hour of initiation of iNO iNO response is considered positive if the PaO2/Fio2 ratio increase by 20% or if the mean PAP or PVR decreases by 20% from the baseline. If no response with iNO it should be discontinued. If No2 level is more than 2PPM refer to the Dr immediately.

How to connect and monitor iNO. Nitric oxide cylinder needs to be changed if the cylinder reaches 500 psi..

Complications / Side effects. Methemoglobinemia Blurred vision Confusion Anemia Dizziness and faintness.

Reference. http://www.circulationaha.org.